lymphography by dr/ dina metwaly lymphatic system lymphatic system it is part of the circulatory...
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LymphographyLymphographyByBy
Dr/ Dina MetwalyDr/ Dina Metwaly
lymphatic systemlymphatic system
it is part of the circulatory system, comprising a it is part of the circulatory system, comprising a
network of lymphatic vessels that carry a clear network of lymphatic vessels that carry a clear
fluid called lymph directionally towards the fluid called lymph directionally towards the
heart. heart.
The lymphatic system consists of lymphatic The lymphatic system consists of lymphatic
organs, a conducting network of lymphatic organs, a conducting network of lymphatic
vessels, and the circulating vessels, and the circulating lymph..
The Lymphatic System functionsThe Lymphatic System functions
Slide 12.1Slide 12.1
Transport clean fluids back to the
blood
Drains excess fluids from tissues
Removes “debris” from cells of
body
Transports fats from digestive
system
Lymphatic SystemLymphatic System
Thymus Thymus Gland Gland
Lymph Lymph VesselsVessels
Lymph NodesLymph Nodes Spleen Spleen Tonsils Tonsils
Lymphatic CapillariesLymphatic Capillaries
Fluid leaks through mini-valves into lymph capillaries
Higher pressure on the inside closes mini-valves
Lymphatic VesselsLymphatic Vessels
Collects lymph from lymph
capillaries
Delivers lymph to lymph nodes
Returns fluid to circulatory
veins near the heart
Right lymphatic duct
Thoracic duct
Lymphatic System StructuresLymphatic System Structures
Lymph NodesLymph Nodes
Filter lymph before it is
returned to the blood
Defense cells in nodes:
Medulla houses macrophages
which engulf and destroy
foreign substances
Cortex nurtures lymphocytes
which provide immune
response to antigens (cortex)
Lymphoid OrgansLymphoid Organs
Several other organs
contribute to lymphatic
function
1. Spleen
2. Thymus
3. Tonsils
4. Peyer’s patchesFigure 12.5
The SpleenThe Spleen
Filters blood
Destroys worn out blood cells
Forms blood cells in the fetus
Acts as a blood reservoir
The ThymusThe Thymus
Functions at peak levels
only during childhood
Produces hormones (like
thymosin) to program
lymphocytes
TonsilsTonsils
Small masses of lymphoid
tissue around the pharynx
Trap and remove bacteria and
other foreign materials
Tonsillitis is caused by
congestion with bacteria
Peyer’s Patches Peyer’s Patches “Tonsils of the intestine” “Tonsils of the intestine”
Found in the wall of the small intestine
Capture and destroy bacteria in the
intestine
LymphographyLymphography
General term applied to the General term applied to the
radiologic examination of:radiologic examination of:
Lymph nodesLymph nodes
(lymphadenography) : (lymphadenography) :
radiographic visualization of the radiographic visualization of the
lymph nodes . lymph nodes .
Lymph Vessels: endovascular Lymph Vessels: endovascular
injection of radiopaque material injection of radiopaque material
into a lymphatic vesselinto a lymphatic vessel
Usually done to demonstrate pelvis and Usually done to demonstrate pelvis and
abdomenabdomen
Injected in footInjected in foot
For axillary, clavicular area and upper limbsFor axillary, clavicular area and upper limbs
Injected in hand Checks drainage of lymph Injected in hand Checks drainage of lymph
nodesnodes
IndicationsIndications
Edema in limbs by Edema in limbs by
Visualization of vessel Visualization of vessel
obstructionobstruction
InfectionsInfections
Rule out cancerRule out cancer
Lymphoma staging & Check Lymphoma staging & Check
for metastasisfor metastasis
Size, shape, location of Size, shape, location of
enlarged nodesenlarged nodes
Fluoroscopy guided biopsy Fluoroscopy guided biopsy
ContraindicationsContraindications
PregnancyPregnancy
People with allergies to iodine-based People with allergies to iodine-based
contrast dyes.contrast dyes.
people with severe chronic lung, heart, people with severe chronic lung, heart,
kidney, or liver disease.kidney, or liver disease.
Pre ProcedurePre Procedure
Obtain PT history Obtain PT history
Obtain PT consentObtain PT consent
Make sure to have all supplies Make sure to have all supplies
Make sure the absence of contraindications, Make sure the absence of contraindications,
which are cardiovascular or pulmonary which are cardiovascular or pulmonary
diseasedisease
Positioning aides and comfort suppliesPositioning aides and comfort supplies
ContrastContrast
Water based (less commonly used as it diffuse in Water based (less commonly used as it diffuse in
nearby tissues).nearby tissues).
Oil based Oil based
More commonly usedMore commonly used
EthiodalEthiodal
LipodalLipodal
Dose: The total amount of oily contrast medium Dose: The total amount of oily contrast medium
injected on each side should never exceed 10 mLinjected on each side should never exceed 10 mL
Procedure of lower limb Procedure of lower limb lymphography ( pedal lymphography ( pedal lymphangiography)lymphangiography)
Injection of mixture of local anesthesia + methylene Injection of mixture of local anesthesia + methylene
blue violet on the dorsal aspect of the foot between the blue violet on the dorsal aspect of the foot between the
toes.toes.
longitudinal incision ---> isolation of lymphatic vessel longitudinal incision ---> isolation of lymphatic vessel
from the surrounding fatty tissue from the surrounding fatty tissue
visualization of superficial collectors after visualization of superficial collectors after
subcutaneous injection of contrast materialsubcutaneous injection of contrast material
1.1. into the first and second inter-metatarsal spaces into the first and second inter-metatarsal spaces
of the dorsal foot (for superficial circulation)of the dorsal foot (for superficial circulation)
oror
2.2. or lateral retro-malleolar space (for deep or lateral retro-malleolar space (for deep
circulation)circulation)
Nodes in pelvis and abdomen are demonstrated Nodes in pelvis and abdomen are demonstrated
with foot injectionwith foot injection
A needle or catheter is inserted into a lymphatic channel in A needle or catheter is inserted into a lymphatic channel in
either the foot or arm, and a contrast medium is injected either the foot or arm, and a contrast medium is injected
into the body at a very slow rate (approximately 60 to 90 into the body at a very slow rate (approximately 60 to 90
minutes for all the contrast medium to be injected).minutes for all the contrast medium to be injected).
A fluoroscope is used to follow the dye as it spreads A fluoroscope is used to follow the dye as it spreads
through the lymphatic system through the legs, into the through the lymphatic system through the legs, into the
groin, and along the back of the abdominal cavity.groin, and along the back of the abdominal cavity.
Once the contrast medium is injected, the catheter is Once the contrast medium is injected, the catheter is
removed, and the incisions are stitched and bandaged.removed, and the incisions are stitched and bandaged.
FilmingFilming
X-rays are usually taken 1 HR after pressure X-rays are usually taken 1 HR after pressure
injection that takes about 45 minutesinjection that takes about 45 minutes
After 1 hourAfter 1 hour
24 hrs24 hrs
48 hrs (if needed)48 hrs (if needed)
72hrs (if needed)72hrs (if needed)
First hourFirst hour= = Contrast in lymph ductsContrast in lymph ducts
24 hours 24 hours = = If lymph nodesIf lymph nodes
After 1 hour= After 1 hour= LymphangiogramsLymphangiograms
the first films are taken the first films are taken
usually of the lymph usually of the lymph
vesselsvessels the upper body or the upper body or
any area of interest. any area of interest.
These first flims are called These first flims are called
“Lymphangiograms”!“Lymphangiograms”!
LymphadenogramsLymphadenograms
24 hours after the 24 hours after the
Lymphangiograms Lymphangiograms
are taken the patient are taken the patient
has to come back to has to come back to
have the films taken have the films taken
of the lymph of the lymph nodes nodes
called called
“lymphadenograms!”“lymphadenograms!”
upper limb upper limb lymphography lymphography
injection of contrast agent in a collector of injection of contrast agent in a collector of
dorsal radio-carpal surface (for superficial dorsal radio-carpal surface (for superficial
circulation) or ulnar retro-styloid location circulation) or ulnar retro-styloid location
(for deep circulation) (for deep circulation)
radiography of the lymphatic channels from radiography of the lymphatic channels from
forearm to axillary lymph nodesforearm to axillary lymph nodes
Upper Limb Upper Limb LymphographyLymphography
Normal appearances and Normal appearances and variationsvariations
1.1. Normal appearance of lymph nodes.Normal appearance of lymph nodes.
a)a) Lymphogram (filling phase): shows a homogeneous Lymphogram (filling phase): shows a homogeneous appearance of the lymph nodes. appearance of the lymph nodes.
b)b) Lymphogram (nodal phase): shows a smooth peripheral Lymphogram (nodal phase): shows a smooth peripheral indentation (arrowheads), which corresponds to the hilar indentation (arrowheads), which corresponds to the hilar area. area.
a) filling b) Nodal
Para-aortic nodes have proved to Para-aortic nodes have proved to
be the most reliable group for be the most reliable group for
showing features of high showing features of high
diagnostic accuracydiagnostic accuracy
The cisterna chyli is usually a The cisterna chyli is usually a
saccular structure less than 5 cm saccular structure less than 5 cm
in length usually lies at the in length usually lies at the
midline of the body of L1 but may midline of the body of L1 but may
also be situated on either side of also be situated on either side of
the midline. the midline. Lymphogram shows normal cisterna chyli and the abdominal segment of the thoracic duct.
The thoracic duct sharply merges into the junction of The thoracic duct sharply merges into the junction of
the left subclavian vein and left internal jugular veinthe left subclavian vein and left internal jugular vein
Some rarely seen nodes are situated extrinsically to Some rarely seen nodes are situated extrinsically to
the usual lymphographic regions, such as the the usual lymphographic regions, such as the
popliteal, posterior intercostal, mediastinal, bilateral popliteal, posterior intercostal, mediastinal, bilateral
hilar, paratracheal, and supraclavicular nodeshilar, paratracheal, and supraclavicular nodes
Figure: Lymphogram shows Normal appearance of the thoracic duct. the termination of the thoracic duct at the left subclavian-jugular venous anastomosis at the base of the neck
Iliopelvic-aortic Lymphatic Iliopelvic-aortic Lymphatic SystemSystem
Iliopelvic Abdominoaortic Iliopelvic Abdominoaortic Lymph NodesLymph Nodes
Inguinal RegionInguinal Region
LymphographyLymphography
Lipiodol lymphography: Left image: After the injection of contrast material (lymphangiographic phase) the normal lymphatic vessels of the minor pelvis are visualized. Right image: 24 hours after the injection normal inguinal, pelvic and paralumbar lymph nodes are demonstrated (nodal phase).
complicationscomplications
The major complications of lymphography are The major complications of lymphography are caused by the vital dye and contrast materials caused by the vital dye and contrast materials rather than the techniquerather than the technique
Major frequent complication: Major frequent complication:
1.1. pulmonary oil embolizationpulmonary oil embolization
2.2. Pulmonary infarctionPulmonary infarction
3.3. hypersensitivity to methylene blue dye and hypersensitivity to methylene blue dye and ethiodized oilethiodized oil
Rare complication:Rare complication:
1.1. intraalveolar hemorrhageintraalveolar hemorrhage
2.2. hypothyroidismhypothyroidism
3.3. systemic arterial embolization to the brain or systemic arterial embolization to the brain or kidneykidney
Post ProcedurePost Procedure
1.1. Watch for signs of infection Watch for signs of infection
Swelling red and warm to touchSwelling red and warm to touch
Accompanied by a feverAccompanied by a fever
Contact DR right awayContact DR right away
2.2. Drink lots of waterDrink lots of water
3.3. Major swelling in one limbMajor swelling in one limb
Especially limb injectedEspecially limb injected
ConclusionConclusion
This procedure has largely been replaced by non-This procedure has largely been replaced by non-
invasive MRI or CT procedures.invasive MRI or CT procedures.
However, lymphography has the unique capability However, lymphography has the unique capability
of demonstrating internal architectural of demonstrating internal architectural
derangements within normal-sized lymph nodes. derangements within normal-sized lymph nodes.
This highly valuable advantage makes This highly valuable advantage makes
lymphography diagnostically more accurate than CT lymphography diagnostically more accurate than CT
(which demonstrates size rather than architecture) (which demonstrates size rather than architecture)
Lymphography still has a cornerstone role in Lymphography still has a cornerstone role in
diagnosis and management of lymphatic circulatory diagnosis and management of lymphatic circulatory
disorders. disorders.
Q & A?Q & A?